The role of WHO’s MHD&AP as a knowledge-based regulatory instrument in the mental health policy processes in Hungary

Mental Health Declaration and Action Plan had regulatory effects on the national level, since an issue that had formerly been absent from the national agenda has been brought up, partly as a result of the formal collaboration between WHO and Hungary, but mainly as a result of self-regulation, i.e. the European/international ‘language’ of mental health policy was adopted partly as a way of conformity, partly as a rational step in the hope of funding possibilities.

As a result of the WHO initiatives the first Hungarian National Programme of Mental Health was produced. The Programme noticed every subject of MHD&AP. In this sense one can speak of an Europeanization process in the field of mental health policy in Hungary, in line with which a domestication process was taking place, i.e. domestic factors (pre-existing structures, traditions, domestic interests, organizational capacities) had very significant effect on the policy process. Europeanization processes and domestication processes complemented each other in the course of the international policy transfer (Bugdahn, 2005, 181). It has been often argued that transferring policy ideas across cultural, linguistic and national boundaries are complex cultural, political and social practices, and as such, are far from being mechanistic, top-down, and exclusively formal processes. Instead, it should be seen as a process involving negotiations and translations as the result of forces of domination and resistance at the same time (Lendvai & Stubbs 2007, 188-189).
Indeed, in the course of transferring mental health policy ideas from the European level to Hungary a remarkable translational process were taking place. As Nassehi (2008) and Sturdy (2008) pointed out in their dialogue for KNOW&POL research about making knowledge observable, knowledge is always context dependent. The MHD&AP as a knowledge-based instrument was constituted within a context where the structure of psychiatry was fundamentally different than in Hungary, deriving its relevance from this context. As we could see Hungarian actors did not take real part of the procreation of the document in as much as their experience of the national field of mental health policy had been very different. The language MHD&AP had used was unfamiliar for most of the Hungarian actors. As MHD&AP was transferred to Hungary, it was transferred into a fundamentally different context. It had to be reinterpreted to suit this context: “transfer from one social space to another necessarily accompanied by a translation of meaning” (Sturdy 2008:1).

Mahon in her Integrative report for Orientation 1 of the KNOW&POL Project used the model of “punctuated equilibrium” describing the Eastern European transformation period, according to which model the changes taking place in these countries opened the way for structural change in the policy processes. Following the model of “punctuated equilibrium” Hungary could have been a hospitable environment for a path-breaking process in mental health policy; we found, however, that although formally Hungary accomplished the expectation of WHO, there was considerable resistance against the fundamental reconsidering of the mental health service in Hungary which resulted in the translation of WHO’s intentions in a way that they could be fit into the existing structures.

One reason that contributed to the translation of mental health to psychiatry (i.e. the substitution of the larger mental health paradigm by a narrower understanding of mental health, reduced to hospital psychiatry) was the structure of the Hungarian mental health field, which – despite the political change, the restructuring of the health care financing system, and the recent health reforms – did not go through a fundamental change. Quite the contrary, the positions in the field had been reinforced by the appearance of the pharmacological industry in the early 1990’s. Since then, the structure of the psychiatric field has been consolidated by the economic influence of the pharmacological companies. The mental health policy community is still very much institutional psychiatry centred. Professionals providing alternative type of care and prevention are in a position of insignificant power. The recently emerged non-governmental organizations composed of users of mental health service and/or their families are weak, as they are only in the phase of seeking voice and finding possibilities. Consequently, the psychiatrists who are in position of power and authority in the field have commanding lobbying capacities, having close formal and informal connections with the Ministry, and thus are in positions to represent Hungary in the international policy community. This lobby group of hospital psychiatrists, exploiting the temporary disinterestedness of the Ministry, appropriated the WHO instrument, and later they manœuvred themselves into an advantageous position in which they were able to present themselves for the Ministry as the primary competent professional group in mental health policy.

On the other hand, in order to understand the translational process of mental health policy in Hungary, it is important to see the process from the perspective of the Ministry of Health. Hungary is in a double-bind dilemma in terms of policy formation. On the one hand Hungary tries to conform to the “European expectations”, on the other hand the existing structures, established operational mechanisms, economic constrains often frustrate the reception of both policies and policy procedures. Therefore, even though in formality Hungary endeavours to embrace every European policy, or policy procedure, in effect the country is absorbed by its own problems. In other words, Hungary’s main concern is to maintain face in Europe in the Goffmanian sense. The following example can throw illustrative light on this.

“For a long time Hungary was deferring the data transmission, which made the relation strained, finally they sent the data. After that, I let the Ministry know that I was aware of the invalidity of some of the data. I do not know the exact numbers, but for example I am aware that there are not 1,300 psychiatrists in Hungary, which was a figure they were talking about. I do not know where this figure was came from, maybe the number of those who had taken a specialty exam in psychiatry in the past 40 years, but only around half of them work as a psychiatrist in Hungary. 1,300 is certainly a false figure” (The Mental Health Counterpart about the “face-lifted” data sent for the WHO baseline report).

Similarly, in line with the European expectations the call for more transparent policy processes is more and more compelling in Eastern Europe (Stan 2007). In the name of transparency and international harmonization, the Hungarian Ministry of Health drew on international standards in the course of the framing process of the national policy. We call this process a (purely) procedural europeanisation. In the name of participation, diverse ‘empowered’ actors were involved, including consumer groups, NGOs, professional organisations, etc. The amorphous concept of participation created ‘indeterminate involvements’ (involvement without clearly defined decision rights) on which the legitimacy of the process and its end result could be established (Clarke, 2007; Newman & Clarke, 2009). Although on the surface the Ministry ceded power to others, in fact its power had simply taken other forms than before. Even though the Ministry put up the drafts of the policy under formulation onto its website, inviting comments from the public, and arranged conferences and debates, still the allocation of who got to enter, what counted as relevant knowledge and expertise, what was the weight of the different voices determined the future outcome.

For the Ministry’s perspective the Hungarian Mental Health policy had to satisfy three criteria. It had to have some sort of connection to the WHO mental health initiatives, it had to be accepted in the Hungarian mental health community (dominated by classical hospital psychiatrists) and it had to be feasible under the current economic conditions. The translational process described in this paper turned out to be the solution.

BUGDAHN Sonja (2005), Of Europeanization and domestication: the implementation of the Environmental Information Directive in Ireland, Great Britain and Germany, Journal of European Public Policy 12, 177-199.